Senior Director, Medical Economics

Senior Director, Medical Economics

Success Measures:

• In 3 months:
• Understand the data within our Product Suite and the market value of our applications.
• Conduct ad hoc analysis on our data to identify opportunities or troubleshoot issues.
• Utilize database queries (P-SQL) to explore our data, our grouper models and our service categories.
• Identify, monitor and analyze principle health care cost drivers, by market segment, facility or provider, including utilization and referral patterns including reimburse rates (with factors such as allowed vs paid).
• Explain the logic within our grouper methodologies to a non-technical, non-healthcare person.
• In 6 months:
• Work with Client Success, Product and Technology to define MVP/Proto-type for Specialty Analytics Product to drive financial/PMPM insights which improve cost efficiencies and drive quality outcomes for at least one client
• Forecast results for quality, contract risk, financial opportunities and general Value-based Care (VBC) metrics.
• Lead analysis on comparison of different grouper methodologies (e.g., PACES, Prometheus, BPCI, etc.).
• Provide guidance on encounter-based vs person-based vs episode-based analytics in relation to our products.
• Analyze claims, membership and prior authorization data to identify early signs of trends or other issues related to medical care cost.
• Work with engineering to build quality checks, new analytics metrics and design value-add user reports.
• In 12 months:
• Implement Specialty Analytics with at least 2 additional clients and define scalability plan to address any noted challenges
• Utilize industry standards (such as HCC, RAF, CDPS) to overlay new forecast models onto our bundle/grouper models.
• Interpret client contract language to surface clear understanding or business rules, opportunities, short and long-term goals and critical reporting requirements.
• Coordinate program implementation with our Network Services and Provider Enablement teams to establish controls and metrics to validate and assure client goal success.

Responsibilities:

• Value new medical cost initiatives, applying financial modeling expertise and using independent judgment to determine the best methods and approaches to calculate accurate estimates of program savings.
• Conduct comprehensive analysis of healthcare data, claims, and financial reports to identify trends, patterns, and opportunities for improvement.
• Develop and implement advanced statistical models to assess healthcare costs, utilization, and performance metrics.
• Collaborate with internal and external partners to create accurate and insightful reports and enable critical decision making, including definition of features and functions to enable productization of insights.
• Provide analytical support for strategic initiatives, such as contract negotiations, provider network optimization, and total cost of care management.
• Evaluate the financial impact of proposed changes and initiatives, recommending data-driven strategies to optimize outcomes.
• Coordinate program implementation with initiative owners and establish controls to validate that changes have occurred.
• Thoroughly vet and perform due diligence on potential value-based arrangements to assess financial impact, ensure operational feasibility, and identify impact on existing programs.
• Identify favorable and unfavorable performance trends within medical cost initiatives, communicate trends to leadership, and recommend changes to initiative owners to improve performance.
• Perform complex return on investment analyses for clients to determine if their financial and clinical performance is achieving desired results.
• Keep abreast of Commercial, Medicaid and Medicare reforms and their impact on our clients.

Position Requirements:

• Bachelor’s degree with a concentration in Finance, Accounting, Business, or Healthcare Administration, or equivalent work experience.
• Deep knowledge of value-based care and/or population health management.
• Progressive experience leading and performing analytical work within the healthcare industry (i.e., hospitals, network, ancillary, medical facilities, healthcare vendor, commercial health insurance company, large physician practices, managed care organization, etc.).
• Work experience with SQL where you have created SQL queries, pulled large data sets, and performed data manipulations/analysis.
• Experience with MS Excel functions that include working with large data sets, creating standardized reports, utilizing VLOOKUP and advanced functions/ formulas, creating, using, and interpreting pivot tables, filtering, and formatting.
• Experience using business intelligence (BI) tools to build complex reports.
• Skilled at using data to tell financial stories with recommendations on how to create PMPM efficiencies and reduce cost
• Knowledge of healthcare financial terms such as cost, utilization, Per Member Per Month (PMPM) and revenue.
• In-depth knowledge of Medicaid and/or Medicare programs or other healthcare plans.
• Self-motivated, creative problem solver who can work independently and collaborate through strong communication and interpersonal skills.
• Excellent written and verbal communication skills, including comfort interacting with C-suite.
• Ability to travel up to 10%.

Preferred Qualifications:

• Deep knowledge of grouper methodologies across encounter, person and episode-based analytics.
• Start-up experience and aptitude.
• Experience collaborating effectively with a hybrid and/or fully remote team.
• Strong project management experience and ability to handle multiple projects in a fast-paced environment.
• Demonstrated understanding of key managed care concepts and provider reimbursement principles such as risk adjustment, capitation, FFS (Fee-for-Service), Diagnosis Related Groups (DRG’s), Ambulatory Patient Groups (APG’s), Ambulatory Payment Classifications (APC’s), and other payment mechanisms.
• Experience using Tableau.

Position Perks:

• FREE medical, dental, and vision insurance for employees on select plans
• $1740 annual contribution into qualifying HSAs
• UNLIMITED time off
• Matching 401(k) plan
• Mac laptop and accessories
• Company-paid short-term and long-term disability
• Company-paid life insurance
• Employee Assistance Program
• Annual professional development stipend

• Implementing and acting in accordance with the organization’s information security policies
• Protecting assets from unauthorized access, disclosure, modification, destruction, or interference
• Executing particular security processes or activities
• Ensuring responsibility is assigned to the individual for actions taken
• Reporting security events or potential events or other security risks to the organization